Provider Demographics
NPI:1760939987
Name:WK ALLERGY AND ASTHMA CLINIC
Entity Type:Organization
Organization Name:WK ALLERGY AND ASTHMA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-8951
Mailing Address - Street 1:2300 HOSPITAL DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2394
Mailing Address - Country:US
Mailing Address - Phone:318-227-7946
Mailing Address - Fax:
Practice Address - Street 1:2300 HOSPITAL DR STE 345
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2194
Practice Address - Country:US
Practice Address - Phone:318-227-7946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-06
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory ImmunologyGroup - Single Specialty